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Manorcare of South Holland Ratings & Violations

Manorcare of South Holland is a 216 bed nursing home it provides its nursing home facilities to elderly members of the public. It is located in Cook County, Illinois at:

Manorcare of South Holland
2145 East 170th St.
South Holland, IL 60473
The official records of the state nursing home board show that it provides its health care services for the following health related issues:

  • Alzheimer Disease
  • Neoplasms
  • Endocrine/Metabolic
  • Blood Disorders
  • Mental Illness
  • Circulatory System
  • Respiratory System
  • Digestive System
  • Nervous System
  • Skin Disorders
  • Genitourinary System Disorders
  • Musculo-Skeletal Disorders
  • Other Medical Conditions

Critical Findings Regarding Patient Care at Manorcare of South Holland From State Inspection Surveys Conducted at the Facility

According to the data gathered from the nursing home surveys conducted by the Illinois Department of Health and other survey agencies, there have been noticeable signs of abuse and neglect at Manorcare of South Holland, which can be construed as nursing home negligence. On examining the records, our nursing home attorneys discovered the following:

  • Failure to administer the prescribed formula for gastronomy tube feeding: “R20’s diet order includes an enteral feeding of 1.2% concentration at 75 ml/hr. and NPO (nothing by mouth). During the medication pass observation with E17, Nurse on 9/12/12 at 8:20 AM, R20 was noted receiving an enteral feeding of 1.5 % concentration per gastrostomy tube at 75 ml an hour, with 300 ml remaining. The container did not have a patient identifier, date and time started, the prescribed rate nor the name of the person who started the feeding. On 9/14/12 at 11:15 AM, E20, Registered Dietician explained that the difference in the formula concentrations is the number of calories per ml. E20, Registered Dietician said R20’s assessment for the 1.2% concentration was sufficient for R20’s caloric needs. E20 said that age, [DIAGNOSES REDACTED]. E20 stated that it is projected that R20’s tube feeding will be for long term. E20 said a feeding that meets the caloric needs with the least concentration of calories per ml is generally tolerated better by the digestive system over long periods of time.”
  • Failure to provide consistent supervision to residents at risk of falls: “On 9/14/12 at 12:00 PM, E21, Physical Therapist said that she performed the initial assessment for R15 but could not recall her very well. When reviewing the assessment, E21 stated that the documentation indicated that R15 was unable to sit upright on the edge of the bed without falling forward due to flexion. When asked about R15 sitting in a wheelchair, E21 stated that documentation indicated that R15 would require constant supervision when in a wheelchair. The incident report dated 8/17/12 indicates R15 was sitting in a wheelchair across from the nurse’s station. According to the incident report, R15 scooted forward in the wheelchair, lost her balance and fell and sustained a laceration to the left side of her head. On 9/13/12, 11:45 AM, E16(nurse) stated, “She was sitting directly across from the nurse’s station. We saw her bending forward from the waist and I jumped up, moved from behind the nurse’s station and she toppled over. ” E16 said there were other people present at the desk.”
  • Failure to provide timely incontinent care to residents with pressure ulcers: “Closed record review shows R4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nursing assessment dated [DATE] states R4 has very limited mobility, requiring extensive assistance for transfer, bed mobility and toileting. R4 is alert and oriented. Excoriation to left buttocks with an open area measuring 1.0 centimeter (cm) X 1.0cm was noted. There is no evidence that this skin breakdown was being monitored once discovered. Z4, Family member, stated during a telephone interview on 1/26/12 at approximately 9:45am, that she visits R4 on a daily basis and often found R4 with wet diaper. On 12/25/11 during a visit, R4 ‘ s room emitted a high urine odor. A Certified Nurses’ Aid (CNA) came into the room to provide incontinent care. Z4 stated she assisted the staff with the hygiene care and noted spots of blood on the bed sheet and a “cut” that extended from the testicle to the shaft of the penis. Z4 stated that the CNA got the nurse to come into the room and both nurse and CNA were shocked at what they saw. Z4 said that R4 told her that the staff do not answer the call light and he, R4, would fall asleep with a urinal in place.”
  • Failure to follow physician’s order: “A review of R1 ‘ s physician orders [REDACTED]. According to R1’s current MDS(minimum data set), dated 4/30/10 under special treatments; oxygen therapy. According to R1’s current care plan dated 4/29/10, R1 is at risk for respiratory impairment related to [MEDICAL CONDITION]. Goal noted maintain a patent air way. Intervention noted to administer oxygen as per physician order. On 5/18/10at 11:20am R1 was observed sitting up in a wheel chair in his doorway. R1 was observed with oxygen nasal cannula located on the top of his head. R1 ‘ s cannula was attached to a small oxygen tank administering oxygen at a rate of 3 liters/minute. E8 said that R1 has a behavior of removing oxygen from face and placing it on his head, and that staff has to redirect R1 when it occurs. A review of R1 ‘ s current plan of care denotes no behaviors of R1 removing oxygen and needing to be redirected. No interventions noted or implemented to provide R1 assistance with maintaining continuous oxygen as prescribed.”
  • Failure to ensure residents are free from serious medication errors: “A review of the facility ‘ s incident report dated 5/4/10 6:00pm denotes R3 was administered Gabapetin 18 milliliters (ml), mistakenly and that R3 was on Gabapetin before but has been discontinued. The report indicates that R3’s physician was notified at 7:00pm 5/4/10. The report notes that R3 was asymptomatic, of any drug reaction, vital signs are noted within normal limits, and staff will continue to monitor R3. The report indicated that E11(nurse) administered the discontinued medication.”

Professional Nursing Home Attorneys Serving South Holland, IL

Our patient care attorneys at Rosenfeld Injury Lawyers LLC strive to help vulnerable and injured individuals who have experienced neglect and any form of abuse get the closure they deserve. We provide residents of Illinois with experienced Health care lawyers who are dedicated to your cause. We have handled lawsuits covering the following situations:

  • Bed Sores / Pressure Pores
  • Repeated Falls
  • Dropped Patients
  • Fractures
  • Medication Errors
  • Physical Abuse
  • Patient Wandering
  • Wrongful Death

Concerned about a loved one? Take the first step today.

If your loved one has been abused or neglected during an admission to Manorcare of South Holland, or a different skilled nursing facility in Illinois, you should contact an attorney to determine your legal rights. Our nursing home lawyers have experience getting superior results for all types of cases. Put our team to work for your family and get the results that you deserve. All of our initial consultations are free and we never charge a fee without a recovery for you. Talk to an experienced attorney today (888) 424-5757

Disclaimer: The above inspection findings are take from public sources including the State Department of Health and from Medicare inspection conducted at the facility at least every fifteen months. Rosenfeld Injury Lawyers LLC cannot confirm that the content on this site is the most recent information related to the facilities mentions.

The inspection findings published are not complete. You may find the most up to date information here: or

The deficiencies/citations listed on this page may have been corrected or substantially corrected after the date of the inspection and date of publishing this material. This page is a legal advertisement and a resource of information for visitors. This material is not endorsed by the facility noted or by any governmental agency. Rosenfeld Injury Lawyers LLC does not have any affiliation with the facility.

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